Hospitalization Guidelines for
Ostomy Patients
Contents
·
Hospitalization Guidelines for Ostomy Patients
·
Care During Cancer Therapy
·
Herbs & Surgery
·
Surgery for Problem Stomas
·
Do You Get All Your Benefits?
Hospitalization Guidelines
for Ostomy Patients
By Dr.
Lindsay Bard
It is important an
ostomate knows how he/she should be handled differently than a non-ostomate who
enters the hospital. It's up to
you. It is very important to
communicate to medical personnel who take care of you, including every
physician that treats you, that you have an ostomy, and what type of ostomy you
have. Here are some rules to help you
cover the details:
Rule I ... The Cardinal Rule!
If you feel something is being done or going
to be done to you that might be harmful, refuse the procedure. Then explain to the personnel, especially
your physician. They will then decide with you if the
procedure will actually be in your best interests.
Rule 2 ... Supplies
Bring your own supplies to the
hospital. Never assume the hospital will
have the exact pouches or irrigation systems you use. Most hospitals have some supplies
available. These are used for emergency
situations.
Rule 3 ... Laxatives & Irrigations
Follow the points below concerning laxatives
or irrigation practices, according to which type of ostomy you have. Medical personnel often assume all stomas
are colostomies. But, of course,
practices vary among the various types of ostomies.
·
A transverse colostomy cannot be managed by daily
irrigations. The only colostomy that can
be managed by irrigations is the descending or sigmoid colostomy.
But, sigmoid or low colostomies do not have to be irrigated in order for
them to function; many sigmoid colostomates prefer letting the stoma work as
nature dictates. If you do not irrigate
your colostomy, let the fact be known to your caregivers. If your physician orders your bowel cleared,
irrigate your own colostomy; do not rely on others. There is a strong possibility that those
caring for you will not know how to perform an irrigation.
·
Bring your own irrigation set to the hospital.
·
If you have an ileostomy or urinary diversion
ostomy, never allow a stomal irrigation
as a
surgical or
x-ray preparation.
Remember that laxatives or cathartics by
mouth can be troublesome for
colostomates. For ileostomates, they can
be disastrous-- ileostomates should always refuse them. An ileostomate will have diarrhea, may become dehydrated, and go
into electrolyte imbalance. The only
prep an ileostomate needs is to stop eating and drinking by midnight the
night before surgery. An IV should
be started the night before surgery to
prevent dehydration.
Rule 4 ... X-rays
X-rays present special problems for
ostomates, again, differently
managed according to ostomy type:
·
Colostomates must never allow radiology technicians
to introduce barium into your stoma with a rectal tube. It is too large and rigid. Take your irrigation set with you to x-ray and
explain to the
technicians that a soft rubber or plastic catheter F#26 or 28 should be used to
enter the stoma. Put a transparent bag
on before going to x-ray. Have the
technician or yourself place the rubber or plastic catheter into your stoma through
the clear plastic bag. When enough barium is in your large bowel for the x-ray,
the rubber or plastic catheter can be withdrawn and the open end of the bag
closed. The bag will then collect the
barium as it is expelled and can be emptied neatly after the procedure. Once the x-rays are completed, irrigate
normally to clean the remaining barium from your colon. This will prevent having to take laxatives by
mouth after the procedure.
·
An ileostomate may drink barium for an x-ray
procedure, but never allow anyone
to put barium into your ostomy.
·
A urostomy patient can have normal GI x-rays
without any problems. Never allow anyone to put barium in your
stoma. At times, dye may be injected through a soft
plastic catheter into a urostomy
for retrograde ureter and renal studies, often called an ileo-loop study. The same study may be performed on a urostomy patient with a Koch pouch. The dye will be injected via a large syringe;
this can be a very painful procedure, if the dye is not injected very
slowly. Even 5Occ's will create a great deal of pressure in the ureters and
kidneys, if injected rapidly. Remember
to request that the injection be done slowly.
·
For any ostomate who wears a two-piece
appliance: you may remove the pouch just
prior to the insertion of the catheter, and replace the pouch after the procedure is completed. If you wear a one-piece appliance, bring
another with you to the x-ray department to replace the one removed for the procedure. In the event you are incapacitated, and cannot use your hands
to replace your appliance, request that an ET nurse in the hospital be
available to assist you. The ET nurse
will be able to replace the appliance for you before you leave the x-ray
department.
Rule 5 ... Instructions
Bring with you to the hospital two copies of
instructions for changing and irrigating your appliance. Give one to your nurse
for your chart, and keep one with your supplies at bedside. If you bring supplies that are not
disposable, mark them do not dispose.
Otherwise, you may lose them.
Rule 6 ... Communicate!
Again, let me stress that you must
communicate with the hospital personnel who take care of you. You will have a
better hospital stay, and they will have an easier time treating you.
Care During Cancer Therapy
By Kathryn Earhart, RN, CETN; Vicki Mueller, RN, MS,
CETN; Denis Murray, RN, CETN
Reprinted through permission of WOCN Journal. This article was originally intended for
nurses treating ostomy patients.
Living with an ostomy—whether it is newly created or of
long-standing—presents a number of daily challenges. An oncology diagnosis may necessitate
radiation and/or chemotherapy in addition to stoma surgery. Adjuvant therapy may be required immediately
post-operatively, based on tissues pathology or tumor staging, while tumor
recurrence can initiate further oncology treatment. Notable stoma care challenges can result from
cancer therapy or tumor progression. The
ET nurse can provide education and evaluations to minimize any difficulties
that may arise.
Steps that the ET nurse can take once chemotherapy or radiation have
been prescribed include the following:
·
Schedule
an appointment to examine the stoma and peristomal skin, and review the
patient's stoma care procedure to establish a baseline.
·
Discontinue
the use of any appliance with metal in the faceplate or zinc oxide, either of
which can interfere with radiation therapy.
The appliance should be emptied and moved out of the radiation field if possible
to prevent a bolus effect.
·
Discontinue
stoma dilatations or colostomy irrigation during treatment. Infections may occur in immuno-suppressed
individuals through traumatized mucosal surfaces. Additionally, diarrhea is a common
side-effect and negates successful colostomy irrigation.
·
Discontinue
the use of soaps, solvents, ointments or sealants near or in the area receiving
radiation if any skin reactions are noted.
·
Teach the
patient how to gently remove the appliance.
Gentle cleansing of the stoma and surrounding skin with warm water is
allowed. Pat dry and avoid any vigorous
rubbing or toweling. A hairdryer set on
cool may be used.
·
Skin
reactions related to either radiation or chemotherapy can occur. Instruct the patient to report any changes in
the stoma or peristomal skin to the medical staff.
·
Neutropenic
patients—those with a white blood cell count below 2000—should be
fitted with a clean, disposable pouching system. At times when such patients are dangerously
suppressed, some centers utilize a sterile pouching system. A sterile urine culture may be required for
the septic urostomy patient. The
patient's usual pouching system can be resumed when his/her white blood cells
have normalized.
·
Stomal
edema—swelling from an accumulation of an excessive amount of watery
fluid in cells or tissues, ulcerations, and less frequently
necrosis—death of a portion of tissue resulting from irreversible
damage—can be observed. An
enlarged appliance opening may be needed to protect the stoma from trauma. Stomal edema can result from direct contact
with the mucosal lining. Any stomal
ulcers that develop require gentle cleansing and should resolve quickly when
treatment ceases.
·
Counsel
patients to monitor fluid intake and output if nausea, vomiting or diarrhea
develop. The ileostomy patient is
particularly at risk of dehydration and medical intervention may be required to
treat symptoms and/or dehydration.
·
Constipation
can plaque certain colostomy patients taking pain medication or some
chemotherapy drugs or with tumor progressions.
Caution patients to obtain medical/nursing instruction if their bowels have not moved
within 48 hours.
Other, less common complications of the oncology patient include
hemorrhage due to suppressed blood platelets or peristomal varices—caput
medusa (veins radiating from around the stoma).
Peristomal varices present as a bluish or purple discoloration of the
peristomal skin that blanches when pressed.
The skin remains intact, though upon initial examination it appears damaged.
This condition of the liver is related to metastatic
disease—shifting from one part of the body to another, hepatitis and cirrhosis resulting in portal
hypertension—a vein that is obstructed in the liver. The dangerous stomal complication is hemorrhage
at the Mucocutaneous junction—where the stoma meets the abdominal
skin. To minimize the risk of
hemorrhage, the appliance opening should not come into contact with the stoma. Enlarge the opening of the barrier ¼"
larger than the stoma. Soft barrier
rings or stoma pastes can minimize rubbing.
Gentle stoma and peristomal skin cleansing is imperative, as is avoiding
aggressive adhesives or excessive pressure from belts.
Pressure from a soft cloth or gauze can be applied to bleeding
sites. If the bleeding does not stop,
the patient should be instructed to seek medical assistance. Topical treatment includes: cautery,
suturing; application of homeostatic agents.
Surgical treatment and blood transfusions may be indicated.
Candidiasis—fungus or yeast infections—occurs more easily in
the immuno-suppressed patient. A white
coating appears on the stoma and can be scraped off. Peristomal yeast infections can be seen as
erythematous skin—redness of the skin due to capillary
dilatation—with scattered satellite lesions that may cause
pruritis—itching. If the culture
is positive, topical anti-fungal powders or creams can be effective. However, immuno-suppressed patients may
require systemic anti-fungal therapy.
Drug-induced skin reactions are a common side effect of chemotherapy
agents. Drugs reported to cause skin
reactions include 5-fluorouricil, bleomycin, methotrexate, doxirubicin,
actinomycin, taxol, taxotere, thiotepa and melphalan. Gentle appliance removal and cleansing are
indicated. A non-adhesive appliance
using a belt and silicone or karaya rings may be necessary during acute skin
reactions. The skin will improve
post-treatment; however, recall skin reactions have been noted during active
radiation treatment.
There is the potential for tumor recurrence in the stoma mucosa or
peristomal skin, the 5-10 per cent of malignant recurrences appearing
cutaneously—at the base of the stoma.
Direct examination and biopsy can confirm tumor development. Treatment may or may not be indicated. Gentle removal and cleansing, plus the use of
non-adherent and absorbent dressings over friable—a dry and brittle
culture falling into powder when touched—peristomal tumors, will reduce
trauma. Appliance openings may have to
be enlarged due to stomal tumors.
Surgical resection or radiation may be necessary if there is a risk of
stomal obstruction by the tumor.
Preventive stoma care, education and evaluation can minimize the
side-effects of oncology-related treatment.
With the increasing number of therapies for cancer, more stoma patients
are undergoing such treatments. The role
of the ET nurse as a member of the oncology treatment team is therefore
increasingly important.
A new study gives patients and
their physicians specific recommendations for when to stop use of herbal
medications prior to surgery. In the July 11, 2001, issue of JAMA, three University of Chicago physicians
assess the interactions between herbs, anesthesia and surgery and suggest ways
to reduce the associated risks.
Their goal is to
provide a framework for physicians "practicing in the current environment
of widespread herbal use" and to encourage patients and physicians to
discuss the topic openly and in detail prior to surgery.
"While most
of these substances appear to be safe for healthy people, for surgical patients
they can affect sedation, pain control, bleeding, heart function, metabolism,
immunity and recovery in ways that we are just beginning to understand,"
said study author Chun-Su Yuan, M.D., Ph.D., assistant professor of
anesthesia and a member of the Tang Center for Herbal Medicine Research at the
University of Chicago.
Studies suggest
that as many as one-third of pre-surgical patients take herbal medications, but
that many of those patients fail to disclose herbal use during pre-operative
assessment, even when prompted. Further, physicians often are unsure what to do
with the information.
"Physicians
need to specifically ask patients about herbal medication use," said
co-author Jonathan Moss, M.D., PhD, professor of anesthesia
and critical care at the University.
"Many patients think of herbal medications not as supplements but
as drugs. Other patients may not want to admit to their use to physicians. But
in order to optimize patient safety and pain control during and after surgery,
we need to know what herbal as well as over-the-counter or prescription drugs
each patient takes."
Despite their
reputation as "mild" or "natural," herbal medications can
speed up or slow down the heart rate, inhibit blood clotting, alter the immune
system and change the effects and duration of anesthesia.
The American Society of Anesthesiologists has
recognized the potential for adverse reactions and suggests that patients stop
taking all herbal medications two weeks before surgery. This advice may be
difficult to implement, however, since most preoperative evaluations occur only a few days
prior to surgery.
So the Chicago
researchers began to search for more targeted recommendations. Although there are more than 1,500 herbal
medications sold in the United States, they focused on the eight most common
herbs -- echinacea, ephedra, garlic, ginko, ginseng, kava, St. John's wort, and
valerian -- which account for 50 percent of all single-herb preparations sold.
The authors found,
first of all, a shortage of clinically relevant information. There were no
randomized, controlled trials that evaluated the effects of prior herbal
medicine use on the period immediately before, during and after surgery.
However, by
reviewing the biology of the compounds as well as all studies, case reports,
and reviews addressing the safety and pharmacological effects of these eight
medications they came up with the following recommendations:
|
Effects
of herbal medications and recommendations |
|||
|
Herb |
Relevant effects |
Perioperative concerns |
Recommendations |
|
Boosts immunity |
Allergic reactions,
impairs immune suppressive drugs, can cause |
Discontinue as far in
advance as possible, especially for transplant patients or those with liver
dysfunction. |
|
|
Ephedra (ma huang) |
Increases heart rate,
increases blood pressure |
Risk of heart attack, arrhythmias,
stroke, interaction with other drugs, kidney stones. |
Discontinue at least
24 hours before surgery. |
|
Garlic (ajo) |
Prevents clotting |
Risk of bleeding,
especially when combined with other drugs that inhibit clotting. |
Discontinue at least 7
days before surgery. |
|
Ginko (duck foot, maidenhair, silver apricot) |
Prevents clotting |
Risk of bleeding, especially
when combined with other drugs that inhibit clotting. |
Discontinue at least
36 hours before surgery. |
|
Lowers blood glucose,
inhibits clotting, |
Lowers blood-sugar
levels. Increases risk of bleeding. Interferes with warfarin (an
anti-clotting drug). |
Discontinue at least 7
days before surgery. |
|
|
Kava
(kawa, awa, intoxicating pepper) |
Sedates, decreases anxiety |
May increase sedative
effects of anesthesia. Risks of addiction, tolerance and withdrawal unknown. |
Discontinue at least
24 hours before surgery. |
|
St.
John's wort (amber, goatweed, Hypericum, klamatheweed) |
Inhibits re-uptake of
neuro-transmitters (similar to Prozac) |
Alters metabolisms of
other drugs such as cyclosporin (for transplant patients), warfarin,
steroids, protease inhibitors (vs. HIV). May interfere with many other drugs. |
Discontinue at least 5
days before surgery. |
|
Sedates |
Could increase effects
of sedatives. Long-term use could increase the amount of anesthesia needed.
Withdrawal symptoms resemble Valium addiction. |
If possible, taper
dose weeks before surgery. If not, continue use until surgery. Treat
withdrawal symptoms with benzodiazepines. |
|
The authors caution that even this study has
many gaps. Because they are regulated
as dietary supplements rather than medications, herbal medications do not
undergo the safety and efficacy testing required for new drugs. Further, unlike
pharmaceuticals, there is no mechanism to track adverse events caused by herbs.
Herbal medications are even more difficult to
study because the ingredients tend to vary enormously from maker to maker and
even lot to lot. Potency and purity are inconsistent. Product labels are not always accurate.
In fact, Yuan, who studies the effects of ginseng,
has had to work closely with a Wisconsin supplier to obtain consistent supplies
of that herb for his research. Many
physicians remain unaware of potential risks associated with herbal medications
or how they interact with other drugs, note the authors. Medical schools are
just beginning to teach students about herbal preparations and to study their
effects systematically.
"If patients use them--and we know they
do--then we need to know what to expect, how to prevent problems, especially
during surgery, and how to respond when something goes wrong." added
co-author Michael K. Ang-Lee, M.D., senior anesthesia
resident at the University of Chicago.
Surgery for Problem Stomas
By
Arthur J. Vayer, Jr., M.D.
A significant number of ostomates have a problem stoma that may need
surgical correction. In statistics
published for a United Ostomy Association survey, 15% of ileostomates and 10%
of colostomates require surgical intervention for complications associated with
the stoma.
The first, easiest and best step in treating the problem stoma is to
create a stoma correctly. The
foundations of stoma construction are similar to the old real estate saying: Location, location, location.
--Location so that the ostomate may properly care for the stoma. Skin folds and irregular skin surfaces are
avoided, if possible, and the stoma should be visible to the patient, avoiding
placement too low on the belly wall.
Placement should also pay attention to wardrobe considerations, such as
the belt line.
--Location through the rectus
abdominus muscle—the one you use for sit-ups. Placing the stoma through the rectus abdominus muscle takes advantage
of the strongest muscle of the belly wall and minimizes the chance of
developing a hernia.
--Location of the “spout” above the skin. An ileostomy should have a long spout to keep
the caustic small bowel effluent off the skin, while a urostomy or colostomy
should have a smaller sized “bud”.
Despite proper construction, any of several complications can develop
that may require surgical correction.
Retraction
of the stoma is apparent as the “budding” disappears. The most common causes of stoma retraction
are technical problems at stoma creation and port-operative weight gain. Stoma retractions will occur in less than five
percent of all ostomates. Therapy for
stoma retraction can involve weight loss if weight gain is the culprit.
Often this approach is not practical, since many patients had weight
loss from their disease—notably, Crohn’s Disease and ulcerative
colitis—and go back to their normal weight after the disease is
removed. Most commonly, the stoma will
need to be revised surgically. An
intra-abdominal procedure is needed, thereby, making the correction of
retraction a “big deal”.
Stricture of the stoma will first show up as difficulty with evacuation
at the stoma and possibly crampy abdominal pain. The combination of a tight stricture and hard
stool can result in impaction, when the stool truly blocks the stoma and cannot
come out. Stoma strictures occur in less
than five percent of all ostomates.
The stricture is made up of scar tissue and can be at the level of the
skin or fascia—the tough muscle covering.
For skin strictures, the repair is simple and can be done as a local
procedure. Fascia level strictures may
require relocation of the stoma.
Abscesses
or fistulas are relatively common problems after surgery because the bowel is a
“contaminated” organ. Patients
with Crohn’s Disease are the most prone to this complication, since
fistulas tend to develop in Crohn’s Disease anyway. Stoma abscess or fistula will occur in less
than 10% of all ostomates.
If
such an infection occurs, it needs to be drained. Drainage of the infection should be done
either right next to the stoma or well away from the stoma to allow proper
application of the ostomy appliance.
Complicated infections may require stoma relocation and/or revision.
Prolapse
of the stoma is evident as the bowel telescopes out from the body, resembling
an elephant’s trunk. Prolapse will
in occur in less than 10% of all ostomates.
If a prolapse is bothersome or causes symptoms, the stoma will need to
be revised. If there is no other
complication, the surgeon can simply excise the prolapsing length of the bowel
and reform the stoma without relocation.
Stomas with multiple problems might best be served by stoma
relocation.
A
stomal hernia presents itself as a bulge—either next to the stoma or
around the stoma—and results from a defect in the abdominal wall that
allows the intra-abdominal contents to slide next to the stoma. A hernia may be incarcerated or
“stuck”. If a loop of bowel
gets stuck in the hernia, it can present itself as a bowel obstruction with:
crampy abdominal pain, nausea and vomiting.
This scenario is a surgical emergency.
A stomal hernia is the most common problem to develop and will occur in
about 15% of all colostomates. This is
double the rate of occurrence of that of ileostomates or urostomates. There is always a chance for obstruction with
a hernia, so ostomates with a hernia need to be diligent about watching for
signs of obstruction or worsening symptoms.
If a hernia is symptomatic or causes problems with the stoma appliance,
it should be repaired. If the hernia is
small, it can be repaired locally, preserving the location of the stoma. If the hernia is large or is associated with
another problem, the stoma should be relocated.
While
the great majority of ostomates will never have trouble with their stomas, some
will need surgical correction of problems.
The key to successful management of a stoma is to simply “know
your stoma” and investigates when things aren’t right. As always, if you have any questions
regarding your stoma, you can ask your doctor or an ostomy nurse. Remember ... have an ostomy check-up every
few years by your ET nurse.
Do You Get
All Your Benefits?
Adapted from UOA Advocacy Internet Site
More than 5,000,000 seniors are currently missing out on hundreds of
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